Growth and

Development
• GROWTH: increase in size of an individual
due to increase in number and size of the
cells .

• DEVELOPMENT: Qualitative and

quantitative changes and acquisition of a
variety of competences for optimal
functioning in social milieu
• It is related to maturation and myelination
of nervous system.
 SATGES OF GROWTH AND
DEVELOPMENT.
PRENATAL PERIOD
• OVUM 0 – 14 days
• EMBRYO 14 – 8 weeks
• FETUS 9 weeks - birth
PERINATAL PERIOD

22 weeks gestation to 7 days after birth( WHO

1988)

INFANCY
• NEONATE IST 28 DAYS AFTER
BIRTH
• INFANCY IST YEAR OF LIFE
 EARLY CHILDHOOD
• TODDLER 1- 3 YEARS
• PRESCHOOL 3 - 6 YEARS

MIDDLE CHILDHOOD
• SCHOOL AGE CHLD 6 – 10 yrs ( girls)
6 – 12 yrs ( boys)
ADOLESCENCE
• EARLY 10 – 13 yrs
• MIDDLE 14 – 16 yrs
• LATE 17 – 19 yrs
 FACTORS AFFECTING GROWTH AND
DEVELOPMENT.
• GENETIC FACTORS
 PHENOTYPE AND PARENTAL
CHARACTERISTICS.

 RACE

 SEX : Growth spurt occurs earlier in girls . mean

height and weight of girls is less than those in
boys .

 BIORHYTHM & MATURATION

 CHROMOSOMAL ABNORMALITIES
 GENE MUTATIONS
• ENVIORNMENTAL FACTORS
(PRENATAL)
 MATERNAL UNDERNUTRITION/ ANAEMIA
 MATERNAL TOBACCO/ ALCOHOL ABUSE
 HYPERTENSION
 PREECLAMPSIA
 MULTIPLE PREGNANCY
 CHRONIC MEDICAL DISORDERS
 TERATOGENIC DRUG INTAKE
 TORCH/ HEPATITIS B / HIV
• ENVIORNMENTAL FACTORS( POST
NATAL)
 NUTRITIONAL FACTORS
 INFECTIONS/ INFESTATIONS
 TRAUMA
 SOCIOECONOMIC STATUS
 EMOTIONAL FACTORS
 CULTURAL FACTORS
 LAWS OF GROWTH
1. Growth is orderly process occurring in
systematic fashion.
2. Growth follows a sigma shaped curve .
Increments over unit time not always equal.
3. Order of growth is cephalo caudal and distal to
proximal.
4. Rates and pattern of growth are specific to
certain parts of body.
GROWTH PATTERNS OF VARIOUS ORGANS
 Growth regulation

Factors necessary for growth are:

1) Growth hormone.
2) Insulin like growth factors( IGF-1, IGF-2).
3) Insulin.
4) EGF, FGF, TGF-β, PDGF, Nerve growth factors.
5) Erythropoietin.
 ‘SHOX’ gene( short stature
homeobox containing gene)
• Critical for normal growth.
• Pseudo autosomal region of sex chromosomes.
• SHOX mutations have been described in
children with idiopathic short stature and are
implicated in both short stature and skeletal
dysplasia of Turners syndrome.
 INFANCY –CHILDHOOD –
PUBERTY MODEL OF GROWTH
• INFANCY COMPONENT IS CONTINUATION OF
THE FETAL GROWTHAND IS PRIMARILY
DETERMINED BY NUTRITIONAL FACTORS.
• CHILDHOOD COMPONENT IS UNDER THE
INFLUENCE OF GROWTH HORMONE. TALL
CHILDREN SECRETE MORE GH THAN TYHEIR
SHORT PEERS AND GH SECRETORY PULSE
AMPLITUDE CO RELATES WITH GROWTH
VELOCITY.
• PUBERTY COMPONENT IS UNDER THE
INFLUENCE IOF SEX STEROIDS. SPIPHYSEAL
FUSION AND GROWTH CESSATION ARE UNDER
THE INFLUENCE OF ESTROGENS IN BOTH
SEXES.
 ASSESSMENT OF GROWTH
NUTRITIONAL ANTHROPOMETRY
WEIGHT
• At birth approximate weight is 3 kg.
• Infant loses 7 to 8 % ( less than 10%) of
birth weight in the 1st week due to loss of
excess extravascular fluid and poor intake.
• Regains birth weight by 10 to 14 days of
life.
• 0-3 MONTHS GAINS 30 GMS / DAY
• 3 – 6 MONTHS GAINS 20 GMS / DAY
• AT 4 MONTHS WT = 2 × birth weight.
• AT 12 MONTHS WT = 3 × birth weight
• AT 24 MONTHS WT = 4 × birth weight
 WEECH’S FORMULAE FOR WEIGHT

• 3 – 12 MONTHS (A +9)/ 2
• 1-6 YEARS 2A + 8
• 7- 12 YEARS (7A - 5)/2
• Where A is age in months in first formula and age in
years is subsequent two.

IAP CLASSIFICATION OF UNDERNUTRITION

• GRADE EXPECTED WT FOR AGE

• I 70 -79%
• II 60-69%
• III 50- 59%
• IV LESS THAN 50%
• K is post fixed if edema is present.
 MEASUREMENT OF HEIGHT
• Supine length until 2 yrs of age using infantometer.
• In older children stadiometer is used.

Sitting height( subischial - leg length).

• Measure to investigate body disproportion.

• Useful in conditions where spinal growth is affected.
Crown –rump length.

• It is equivalent to sitting height in children les than

2 years.
Arm span: used for

• Investigating disproportion
• Follow up of children with developing deformity like
scoliosis
 HEIGHT VELOCITY
• Birth 50 cm.
• 6 months 60 cm
• 9 months 70 cm.
• 12 months 75 cm.
• Gain during first year is 25 cm.
• Gain during 2nd year is 12.5 cm.
• Gain during 3 rd year is 7.5 to 10 cm.
• Height at 41/2 years is double the birth height i.e
100 cm.
• At 13 years height is triple the birth length.
Adolescent growth spurt continues for a period
of 2.5 to 3 years. In girls it becomes minimal or
stops after the onset of menstruation.
 HEIGHT FOR AGE
Mc Laren classification:
• > 105% of expected giant
• 93 to 105% of expected normal
• 80-93% of expected short
• < 80% of expected dwarf
Waterlow Classification :
• >95% of expected normal malnutrition.
• 90 – 95% marginal
malnutrition.
• 85 – 90% moderate
malnutrition.
• < 85% severe malnutrition.
 BODY PROPORTION

AGE US : LS
BIRTH 1.7 : 1
4 YEARS 1.3 : 1
7 YEARS 1:1

12 YEARS 0.9 : 1
ARM SPAN --- HEIGHT VALUES.

AGE VALUE ( ARM

SPAN MINUS
HEIGHT)
BIRTH - 3 cm

3 YEARS 0

ADULTS +1 cm (girls)
+4 cm ( boys)
 FORMULAE
• Expected height from 2 to12 years.
Height = 6A + 77 cm.

MID PARENTAL HEIGHT:

(FATHER’S HEIGHT+ MOTHER’S HEIGHT)

± 6.5 cm
2
• We add 6.5 cm in case of boys and subtract
in case of girls.

• Target height is +/-8 cm of the mid

parental height and represents height b/w
95th and 5th percentile.
 Head circumference

• During fetal life 70% of brain growth occurs.

• 15% brain growth occurs during infancy.
• 10% brain growth occurs during pre-school
years.

H.C growth velocity.

• 0 – 3 months : 2cm/ month
• 3 months to 6 months: 1 cm/ month
• 6 month to 1 year: 0.5 cm / month

• 1- 3 years: 1 cm / 6 month
• 3 – 5 years: 1 cm / year
• Adult head size is achieved b/w 5 to 6 years.
FORMULA FOR ESTIMATING H.C
CIRCUMFERENCE IN FIRST YEAR.
• ( length in cm +9.5 cm) + 2.5
2
 CHEST CIRCUMFERENCE
• MEASURED AT LEVEL OF NIPPLES
• IN INFANCY C.C < H.C BY 2.5 cm.
• C.C = H.C AT 1 year.
• C.C > H.C BEYOND 1 year.
MID ARM CIRCUMFERENCE
• MEASURED AT MIDPOINT B/W ACROMION
AND OLECRANON.
• 13.5 – 17.0 cm normal
• 12.5 – 13.5 cm borderline
• <12.5 cm malnutrition
 AGE INDEPENDENT
ANTHROPOMETRIC INDICATORS
1. Bangle method
2. Shakir’s tape
3. Quacker arm circumference stick ( Quack
stick).
4. Kanawati index= MAC/ HC
NORMAL > 3.2
It correlates with Gomez classification
Gr I malnutrition 0.28 – 0.32
Gr II malnutrition 0.25 – 0.28
Gr III malnutrition <0.25
5. M.A.C to Height ratio
<0.29 severe malnutrition
0.32- 0.33 normal
6. Ponderal Index
7. Quetelet index = kg /cm² × 100
0.14 -0.16 normal
<0.14 pem
8. Body mass index ( kg/m²).
18.5 – 22.0 normal
<15.0 malnutrition
> 22.0 overweight
> 25.0 obesity
 TISSUE GROWTH
• USEFUL FOR ESTIMATING PERCENTAGE
BODY FAT.
• INSTRUMENTS HARPENDEN’S CALLIPERS
ROSS ADIPOMETER
DENTAL AGE
• LOWER CENTRAL INCISORS 6-8 MONTHS
• UPPER CENTRAL INCISORS 7- 9 MONTHS
• LATERAL INCISORS 9-12 MONTHS
• IST MOLAR 12- 15 MONTHS
• CANINE 18 – 21 MONTHS
• 2ND MOLAR 21- 24 MONTHS
• DENTAL AGE (PERMANENT TEETH)
• IST MOLAR 6 YRS
• CENTRAL AND LATERAL INCISORS 6-8 YRS
• CANINE 9-12
YEARS
• PREMOLARS 9- 12
YEARS
• SECOND MOLAR 12 YRS
• THIRD MOLAR 18 YRS
 BONE AGE
• Skeletal age assessment is based on the fact that
a more mature child will have more bone
development and less cartilage than a less
advanced child
SCORING SYSTEMS FOR BONE
AGE DETERMINATION
1. GREULICH & PYLE SYSTEM
• Childs X- rays are matched to standard plates in
an atlas.
• Atlas plates are based on yearly intervals from
birth to 19 yrs and are separate for boys and
girls
• Accuracy is ± 0.5 yrs in95% of cases.
2. TANNER WHITE HOUSE SYSTEM
(TW3)
• Scoring of epiphyseal maturation of 13
individual bones ( radius, ulna, 1st ,3rd and 5th
metacarpal and phalanges )
• Eight stages of level of maturity are described
from A to H.
• Stage A = absence of bone formation
• Stage B = adult bone status
PRINCIPLES OF DEVELOPMENT
1. It is a continuous process from conception till
maturity.
2. Sequence is same in all children but rate varies.
Development in one field does not necessarily
run parallel with that in other fields. This lack of
parallelism is called ‘DISSOCIATION’.
3. Development is linked to maturation of nervous
system.
4. Generalized mass activity is replaced by specific
individual responses.
5. Occurs in cephalo-caudal direction.
6. Certain primitive reflexes have to be lost before
corresponding voluntary movement is acquired.
 Theories of development

Stages Freud’s Erickson's Piaget’s

theory theory theory
Infancy Oral Basic trust Sensori
motor

Toddler Anal Autonomy -do-

vs. shame

Preschool Oedipal Initiative Pre-

vs. guilt operational

School Latency Industry vs. Concrete

age inferiority operational

Adolescen Adolescenc Identity vs. Formal

ce e identity operational
diffusion
 Gross motor

3 mo Neck holding
5 mo Sitting with support
8mo Sitting without support
9 mo Standing with support
10 mo Walking with support
11 mo Crawling
1 yr Standing without support
13 mo Walking without support with stiff
legs
1.5 yr Running
2 yr Walking upstairs with both feet on
one step
3 yr Riding tricycle& one foot on each
 HAND EYE CO- ORDINATION

4 MO Voluntary grasp

5 MO bi- dextrous grasp

7 MO Palmar grasp
Transfer object from one hand to
another
9 -10 MO Pincer grasp
Scoop a pellet crudely
 EYE CO - ORDINATION

4 WK Regards a ring placed 20 cm infront of

eyes
6WK Follows object by unsteady excursions
of eye
2 – 3 mo Follows object with steady movt

3-6 mo Binocular movt

6-8 mo Depth perception begins

6-7 yr Depth perception complete

HAND SKILLS

13 mo Can turn 2 -3 pages of

book at a time
24 mo Turn one page at a time
Able to wear socks and
shoes
3yr Draw a circle
Can dress and undress
completely
4 yr Can draw + sign
5 yr Can draw × sign & ▲ sign
HAND MOUTH CO ORDINATION

1 YR Tries to feed himself but

spills

15 MONTHS Feeds with spoon with

spilling

18 MONTHS Feeds from cup with

little spilling
 PERSONAL SOCIAL

2 mo Social smile

3 mo Recognizes mother

6 mo Smiles at mirror image

7-8 mo Stranger anxiety

9 mo Waves bye bye

12 mo Plays simple ball game

3 yrs Knows gender

 Language
1 mo Turns head to sound
3 mo Cooing
6 mo Monosyllables
9 mo Non specific Bisyllables
10 mo Understands spoken speech
12 mo 2 words with meaning
18 mo 10 words with meaning
2 yrs Simple sentence with pronouns
3 yrs Can tell story
4 yrs Coherent account of recent
experiences
 TOILET TRAINING

4 mo Gastro colic reflex starts weakening

7 mo Bowel habits irregular

10 mo Child can sit on toilet seat

15 – 18 mo Can walk up to toilet seat

2 yr Trainable

3 yr Can withhold and postpone bowel

movt.
 DEVELOPMENTAL DELAY
• Incidence 10 % of children
• HISTORY
1. Prenatal risk factors ( toxemia, chr medical
illness, infections, drugs/alcohol/tobacco.)
2. Perinatal risk factors ( LBW, prematurity,
multiple gestation.)
3. Neonatal factors ( asphyxia, seizures, IVH,
sepsis, meningitis, kernicterus, hypoxia)
4. Post natal factors ( seizures, sepsis, meningitis,
recurent otitis media , TB)
5. Family h/o
6. Social h/0-
• PHYSICAL EXAMINATION
1. Anthropometry – abnormal growth,
disproportion, malnutrition.
2. Major congenital abnormalities.
3. Minor cong abnormalities. Hirsutism ,
hypertelorism, skin tags.
4. Neurocutaneous stigmata.
5. Abnormal optical findings.
6. Organomegaly, Lymphadenopathy.
7. Neurological findings
 APPROACH TO DIAGNOSIS
1. Appropriate h/o for risk factors and causative insults.
2. Focused physical examination including
anthropometry.
3. Hearing and vision assessment.
4. Developmental screening tests.
5. TREATMENT-
• MULTI DISCIPLINARY APPROACH involving
pediatrician, neurologists , psychologist, ENT,
opthalmologist, orthopedician and physiotherapist.
• Treat underlying disorder if any.
• Psychosocial support to family.
• Peer gp and family counselling
• Special education and rehabilitation
• Physiotherapy and orthopaedic intervention if
needed.
• Visual and hearing aids and speech therapy if